ABSTRACT Over the past two decades, the number of women dying from pregnancy-related causes in the United States has nearly doubled, and cases of severe maternal morbidity have nearly tripled.2, 3 Research concerning the factors influencing pregnancy-related mortality (PRM) and severe maternal morbidity (SMM) has previously neglected women in Central Appalachia, despite the risk profile of this health disparate population. This study utilizes a rigorous mixed methods approach guided by the conceptual framework for action on the social determinants of health adopted by the World Health Organization to identify structural and intermediary determinants influencing Central Appalachian women's risk for SMM and PRM.1, 4 This study is highly innovative in that it is the first study nationally outside the National Center for Health Statistics (NCHS) to utilize a new database from the NCHS, which links morbidity and mortality data. Furthermore, it is the first known study to focus on SMM and PRM in women living in Central Appalachia, and may yield critical intervention insights for this underserved, health disparate population. The following aims will: (1) Identify predictors of PRM and SMM in Central Appalachia. This aim will perform hierarchical logistic regressions on nation-wide data from the NCHS to determine risk and protective factors influencing women's risk of SMM and PRM at delivery and one year postpartum. (2) Elucidate healthcare providers' and patients' perspectives on underlying mechanisms of PRM and SMM in Central Appalachia. In-depth semi-structured interviews will be conducted with: (1) 10 patients who have experienced SMM, and (2) 10 healthcare providers and 10 EMTs in Central Appalachia who have provided care for patients experiencing SMM and PRM. The PI will leverage resources and expertise from the University of Kentucky's Center for Health Equity Research, Research Data Center, and a highly supportive interdisciplinary mentorship team who are experts in rural health disparities, implementation science, and maternal-fetal medicine. Mentorship by team members will provide the PI with ample training concerning the implementation of mixed methods studies, project management, responsible conduct of research, and the dissemination of findings. This training will provide the PI with the skillset necessary to carry out the specific aims, and lay the foundation for the PI to become an independent physician-scientist with an extramurally supported research portfolio in the field of maternal health. Results from this study will produce essential knowledge concerning predictors of SMM and PRM in an at-risk population, and identify factors influencing poor maternal outcomes which may be targeted by future interventions. Findings may also inform development of future empirical investigations into in other rural populations.